Healthcare Provider Details

I. General information

NPI: 1548469208
Provider Name (Legal Business Name): JEDIDIAH JAMES PERKEREWICZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 WASHINGTON AVE
DETROIT LAKES MN
56501-3905
US

IV. Provider business mailing address

1245 WASHINGTON AVE
DETROIT LAKES MN
56501-3905
US

V. Phone/Fax

Practice location:
  • Phone: 218-846-2000
  • Fax:
Mailing address:
  • Phone: 218-846-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number11956
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number54222
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: